Use of Triple Therapy in A Cohort of Patients with COPD Associated Wood Smoke and High Risk: Real Life Study of Five Cases

Abstract

Introduction: Chronic obstructive pulmonary disease associated with exposure to wood smoke (COPD-L) is part of 30% of the etiology of this entity. We know that COPD-L has different characteristics compared to the association with tobacco. There is little worldwide experience in the use of bronchodilators and inhaled steroids in patients with this disease. Currently, the high risk of patients with COPD-L is the main cause of exacerbations and short-term cardiovascular outcome is the cause of increased morbidity and mortality. Triple therapy is currently a treatment used in patients with COPD-T with excellent clinical and symptomatic benefits.

Objective: To describe the effect of triple therapy in a series of 5 cases of patients with COPD associated with wood smoke (COPD-L) after 1-3-6 months of administration, improving symptoms and benefiting lung function.

Methods: Prospective, cross-sectional, observational real-life study carried out in the Department of Pulmonology of a third-level hospital in the City of Puebla in the period from January 1, 2024 to August 1, 2024 in patients with symptomatic L-COPD under the CAT scale despite dual bronchodilator therapy treatment.

Results: 100% of patients were female, exposed to wood smoke with an average of 196 hours/year, Eosinophil count of 338 cells on average, with CAT starting greater than 24 points before treatment and 13 points at the end of treatment at 6 months. Decrease to 50% of the eosinophil count, as well as Decrease in dyspnea 1 point on the MMRc scale and 5 points on the BORG scale.

Conclusion: The cases described offer initial evidence of our medical practice on the benefits of triple therapy in patients with COPD associated with firewood. Beclomethasone/Formoterol/Glycopyrronium have demonstrated good tolerance and safety without presenting adverse effects. These benefits have allowed the patient a better quality of life and a radical decrease in the prevalence of symptoms.

Keywords: COPD, Biomass, Triple therapy, High risk, Wood smoke

Introduction

The treatment of COPD has currently been based on the different international evidence-based guidelines, in this report we have based ourselves on the Spanish guidelines for their great use worldwide and evidence-based (GesEPOC 2022). The COPD patient care process proposes an evaluation in 4 areas: Diagnosis and General Measures, Risk Stratification and selection of the inhaled medication according to symptoms, clinical phenotype and finally approach to treatable traits. In high-risk patients, GesEPOC 2021 recognizes three phenotypes in the pharmacological treatment scheme: Non-exacerbating, eosinophilic exacerbator, and non-eosinophilic exacerbator. Under the above scheme and treatment algorithm, the eosinophilic and non-eosinophilic exacerbating patient benefits from the triple therapy to the increase in symptoms or exacerbation, as well as the increase in the number of eosinophils greater than 300 cells per deciliter in patients with high-risk COPD associated with tobacco. As has been stated, there are numerous writings regarding the association with tobacco but not with exposure to wood smoke. Patients with COPD associated with tobacco and firewood have similarities in some characteristics, especially in the diagnosis, but they also have different physical and clinical characteristics. Patients with high-risk COPD associated with tobacco benefit from triple therapy described in multiple studies for improvement in symptoms, reduction of exacerbations and reduction of mortality, which is why it is relevant to demonstrate in a descriptive way the benefit of triple therapy in the group of patients with high-risk COPD associated with wood smoke. The justification for carrying out the project is in order to have clear and real-life data both symptomatic and clinical of the use of the treatment in a group of patients with the same disease, but associated with another exhibitor and whose benefit has already been widely described in one of them. The importance of demonstrating the improvement in clinical and functional parameters in this group of patients is of utmost importance for its use in patients who present this clinical phenotype, especially in our Mexican and Latin American population. Perez Padilla, Villegas and Sansores et al are so far the only Latin American pulmonologists who have described the benefit of bronchodilators in patients with COPD associated with firewood with excellent results as well as the pathophysiology of the year, taking into account that the survival of patients associated with firewood and tobacco are similar as they have described, because it is beneficial to think that patients with triple therapy benefit from its use. Determining the clinical benefits of patients with high-risk COPD associated with wood smoke in a cohort of patients in a real- life study is of utmost importance in clinical and demonstrates the same benefit that is obtained in patients with high-risk COPD associated with tobacco. However, COPD in general, and exposure studies using in vitro and in vivo model systems to understand the molecular mechanisms of COPD have been investigated primarily in relation to tobacco smoke. Studies on biomass-induced COPD, as well as biomass smoke exposure studies, are limited and the few available are mainly limited to Particulate Matter (PM2.5) wood smoke. Smoke from combustion processes is a complex mixture [1- 6].

Material and Methods

Prospective, cross-sectional and real-life observational study carried out in the Department of Pneumology of a tertiary hospital in the City of Puebla in the period from January 1, 2024 to August 1, 2024. Inclusion Criteria; 1)patients diagnosed with COPD by GOLD/ATS/BTS/SEPAR criteria classified as high risk who attended the Pneumology outpatient clinic, 2) Patient with the use of LABA/LAMA dual bronchodilator therapy. 3) That they agreed to participate and signed a letter of informed consent. 4) Patients who have had an exacerbation in the previous year and persisted symptomatic by CAT score.

a) Exclusion Criteria: Patients with Asthma and Asthma- COPD Over position. Mainly patients who come to the outpatient clinic are described [7-9].

b) Development: Once the diagnosis of COPD was confirmed, the patient had post-bronchodilator spirometry, eosinophils in the blood. It was determined that as they went to the outpatient clinic during the next 1.3-6 months of starting the triple bronchodilator therapy due to previous exacerbation (at least a moderate exacerbation). CAT levels before and after treatment. The clinical dyspnea scales have been standardized in BORG, MMRc which are endorsed by different international organizations to determine the measurement of dyspnea.

Results

100% of female patients were exposed to wood smoke with an average of 196 hours/year, with an average of 196 hours/year, with an average of 338 cells, with CAT starting greater than 24 points before treatment and 13 points at the end of treatment at 6 months. Decrease in eosinophil count to 50%, as well as Decrease in dyspnea 1 point on MMRc scale and 5 points on BRORG scale. (Tables 1 and 2) and (Figures 1 and 2).

Table 1: CLINICAL CHARACTERISTICS OF PATIENTS DIAGNOSED WITH COPD-L (exposure to firewood).

Note*: REL: FEV1/FVC ratio. FEV1: Expired fraction in 1 second

PostBD: Post bronchodilator. ML: milliliters

CAT: COPD ASSESSMENT TEST (COPD Assessment Questionnaire, COPD Impact Test and Quality of Life.

Table 2: CLINICAL IMPROVEMENT OF PATIENTS WITH COPD-L WITH TRIPLE THERAPY (Glycopyrronium/Formoterol/ Beclomethasone).

Note*: CAT: COPD ASSESSMENT TEST (COPD Assessment Questionnaire, COPD Impact Test and Quality of Life.

MMRC Scale: Medical Research Council Modified Dyspnea Scale)

Escala BORG (BORG Rating of Perceived Exertion)

TT: Trpple Terapia.

Figure 1: Improvement of the Cat with Triple Therapy After 6 Months of Treatment.

Figure 2: Evolution of Eosinophils.

Discussion

Patients with L-COPD associated with wood smoke so far are part of a percentage greater than 30% of those associated with tobacco, there is little evidence, but as commented by [3,4] Dr Pérez Padilla, Ramírez and Sansores, et al. have demonstrated the efficacy of double bronchodilation in patients with symptomatic COPD-L in previous studies, So far they are the most outstanding doctors worldwide in the study of patients associated with firewood. This small, real-life study still reflects the presence of patients in Latin America who still cook with firewood and develop the disease over time. It is a small cut of patients in a short period of time, but enough to demonstrate short-term improvement very similar to those described in patients associated with tobacco in several studies with triple therapy [10,11].

Conclusion

This study of 5 real-life patients with L-COPD with high cardiovascular risk demonstrates the improvement of symptoms with the use of triple bronchodilator therapy (Glycopyrronium/Formoterol/ Beclomethasone) with improvement of symptoms, decreased CAT, dyspnea and increase in lung function.

Acknowledgement

None.

Conflict of Interest

None.

References

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